Two years ago, Ashley Hingston had a miscarriage. The 35-year-old Floridian and her husband had been going through in vitro fertilization when they received the news no one wants to get, but which many in their position reflexively expect: "You are going to lose the pregnancy."
On the other end of the line was Hingston's physician, who offered her advice and comfort to ease the pain of the bad news.
"I was a complete wreck and could barely even talk," Hingston recalled. "But I think my doctor knew what I was asking, and she was doing the best to answer the questions I had: Why did this happen? What does this mean? And she sat and listened to me."
An estimated 2% of babies born in the United States each year are the result of IVF, according to 2019 data from the Centers for Disease Control and Prevention. The process is often emotionally, physically, and economically taxing for patients. According to the CDC, the chance a pregnancy will be successful through IVF is 21.3%. Consequently, doctors often find themselves the bearers of bad news.
But interaction with a care team or a string of nurses and providers, rather than a physician, is the norm for IVF patients, according to Aimee Eyvazzadeh, MD, a specialist in infertility and reproductive endocrinology in San Ramon, California.
"Patients see a doctor for all of 10 minutes and then they are handed off to a care team who don't know their whole story," she said.
For Eyvazzadeh and other healthcare professionals, physicians must improve the ways they share bad news, and how they divide tasks with care teams.
Personalized Care Works Best
Providing personalized care will improve how IVF patients respond to bad news, according to Eyvazzadeh and others.
"When people have gone through so much trauma, anything you say to them, sometimes they can't process it very well, so they have to see the information in different ways," she told Medscape Medical News. "After each phone call, I'll actually type up a summary for them, with links and articles for them to read, so they are directed in a way that I think is healthy so they aren't pulled into a rabbit hole."
Eyvazzadeh said she encourages her patients to seek counseling during IVF treatment, and even pays for their initial psychiatric consultation. Not many doctors do this, she noted.
"Taking the time to allow the patient to process the bad news is vital," said Linda Kim, MD, a psychiatrist at Moon Mental Health, to whom Eyvazzadeh refers couples. Sometimes, several calls are necessary.
"Rather than thinking of the conversation as a linear process, consider it a sphere of processing," Kim said. "The patient may need space to grieve, may ask many questions, may need to clarify what happened, or may need to vent and release frustration. This is space that the patient needs to process the bad news." (See sidebar for more tips on how to share bad news with your patients.)
Many care teams are skilled in delivering bad news to patients, according to Liz Grill, PsyD, a psychologist at Weill Cornell Medical College in New York City. The challenge for them is ensuring new nurses and clinicians continue to have empathy training, she said.
"You want to make sure clinicians are building relationships, and empathy. Whether there is a protocol to build that level of empathy, or if they have their own innate ability to build empathy, it's about communicating in the right way," Grill told Medscape.
But Mark Trolice, MD, a reproductive endocrinologist and infertility specialist at the University of Central Florida College of Medicine, Orlando, Florida, agreed that nurses should not deliver bad news, even if they have the expertise and the compassion to do so.
"It's the doctor's responsibility to make that call. It's a very difficult call and it puts an unnecessary burden on your care team to be making these calls all the time," Trolice said. "I feel the patient wants to hear from the physician who oversaw their cycle and did the procedure and embryo transfer. It shows a tremendous amount of responsibility and commitment on the part of the physician."
Trolice also recommended clinicians refer to the HEART (Hearing, Empathy, Apology, Response, and Thanks) guidelines to ensure proper conversations with patients about bad news.
"You give the patient time to process the information and ask questions, and then we schedule another time to talk about plans going forward," he said.
"Patients can feel powerless and not in control of what is happening, or even over their own bodies," Kim added. "To counteract this, it can be helpful to outline projected steps as much as possible."
For Eyvazzadeh, caring for an IVF patient is a matter of knowing your strengths.
Providing links to web resources and sending patients to support groups like organic-conceptions.com (sidebar below) are helpful, she said. "For some people, their strength isn't engaging with patients on the same level that I do. But I still feel like there are ways that we can still make the patients feel cared for without being extreme."
Tips on How to Share Bad News With Patients
1. Get the physical context right
2. Find out how much the patient knows
3. Find out how much the patient wants to know
4. Share the information
5. Respond to the patient's feelings
6. Plan and follow through
Linda Kim, MD, notes that patient preference in receiving bad news is often culturally mediated. She recommends asking patients how they would want to receive bad news, especially in during IVF process, where there can be many challenges over the course of treatment. Kim also recommends these steps:
Get as much information in advance as possible and ask your patient directly how they want bad news. When you are meeting a patient and their families for the first time, and they are filling out their intake paperwork or health forms, you may consider adding a section on "What is your preferred method of communication?" And after that, you might add, "What is the best way to tell you challenging or difficult news? Would you prefer to be by yourself or with a loved one? Please elaborate any additional preferences." Everyone is different, and it can be helpful to hear from the patient directly how they would like to receive bad news. It will not only meet them where they are during a difficult time, it will also demonstrate to the patient that you are respecting their preferences and involving those preferences in the process.
Try to leave enough time for a difficult conversation with a patient. Even better is if a clinician can prepare a patient that there is some disappointing or difficult news to share.
Finally, offer discussion on next steps. It never hurts to ask the patient directly when they are ready to discuss next steps. This may take a few hours, a few days, or even a few months or longer.
Social Media as Support
Monica Wunderman, a patient of Eyvazzadeh's since 2020, began her own social media campaign on Instagram to find support and give support to women experiencing IVF.
"I started scrolling and liking posts, and a girl reached out to me to ask if I needed help" in the form of emotional support, she recalls.
Instagram became a haven for Wunderman to share information, experiences, and support with others. It also allowed her to create a network of support and meet other women, like Ashley Hingston, going through similar struggles.
Wunderman has been through four rounds of IVF so far. Three were completely unsuccessful; the last ended in miscarriage. Although she and her husband are trying again with a surrogate, the uncertainty remains. And she feels the healthcare system should be offering her — and the other would-be parents she has met online — more support.
"We place such importance as a society on growing families," she says. "But then we do very little to support those who want them and struggle."
Lead Image: Noipornpan/Dreamstime
Medscape Medical News © 2022 WebMD, LLC
Send news tips to firstname.lastname@example.org.
Cite this: Breaking Bad News During IVF: How to Soften the Blow - Medscape - Dec 08, 2022.